Stephan Ehrmann1, Charles-Edouard Luyt2,3. 1. Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep Network, CHRU Tours, Tours France and Centre d'étude des Pathologies Respiratoires INSERM U1100, Université de Tours, Tours. 2. Médecine Intensive Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris. 3. Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
Abstract
PURPOSE OF REVIEW: The aim of the article is to review the evidence to select ventilated patients most likely to benefit from inhaled antibiotic therapy and summarize the optimal implementation setup to favor clinical success. RECENT FINDINGS: Although a large body of literature describes the optimal ventilator circuit and settings to implement to favor a high amount of inhaled antibiotic delivery to ventilated patients, recent clinical trials failed to show a significant benefit on patient-centered outcomes. Currently, inhaled antibiotic therapy can only be recommended as a therapeutic modality of last resort after case-by-case discussion among specific patients or settings with high antimicrobial resistances. SUMMARY: Currently, inhaled antibiotic therapy may only be recommended to treat ventilator-associated pneumonia caused by extensively resistant bacteria only susceptible to colistin, and should be used either after documentation of such an infection or empirically in settings with a high probability of such an infection. A similar approach may be considered for aminoglycoside-only-susceptible pneumonia. In these cases, inhaled antibiotics should be ideally delivered as a complement to intravenous therapy placing a vibrating mesh nebulizer upstream in the inspiratory limb, reducing inspiratory flow and increasing inspiratory time, avoiding gas humidification under close clinical and pharmacological monitoring.
PURPOSE OF REVIEW: The aim of the article is to review the evidence to select ventilated patients most likely to benefit from inhaled antibiotic therapy and summarize the optimal implementation setup to favor clinical success. RECENT FINDINGS: Although a large body of literature describes the optimal ventilator circuit and settings to implement to favor a high amount of inhaled antibiotic delivery to ventilated patients, recent clinical trials failed to show a significant benefit on patient-centered outcomes. Currently, inhaled antibiotic therapy can only be recommended as a therapeutic modality of last resort after case-by-case discussion among specific patients or settings with high antimicrobial resistances. SUMMARY: Currently, inhaled antibiotic therapy may only be recommended to treat ventilator-associated pneumonia caused by extensively resistant bacteria only susceptible to colistin, and should be used either after documentation of such an infection or empirically in settings with a high probability of such an infection. A similar approach may be considered for aminoglycoside-only-susceptible pneumonia. In these cases, inhaled antibiotics should be ideally delivered as a complement to intravenous therapy placing a vibrating mesh nebulizer upstream in the inspiratory limb, reducing inspiratory flow and increasing inspiratory time, avoiding gas humidification under close clinical and pharmacological monitoring.